Treatment Authorization Policy

In order to provide better coordination and continuity of care to NEMS Managed Care members, specialist providers are required to obtain Treatment Authorizations prior to the performance of certain procedures and/or services. Services rendered without Prior Authorization from the NEMS Utilization Management Department are subject for Administrative Denial for reimbursement.

Usage of Treatment Authorization Request (TAR) forms applies to primary care providers (PCP), specialist providers, and other service providers. A TAR may be filled out and submitted by the service provider or the PCP.

All providers and specialists should seek Prior Authorization for any services and procedures listed in Attachment A: Services Requiring Treatment Authorization Requests.

Additionally, non-panel providers and non-contracted specialists should seek Prior Authorizations before rendering office visits or office consultations.

Please also refer to Attachment B: Prior-Authorization Exemptions List for a list of services that do not require Prior Authorization. You may also refer to the 1-page NEMS MSO Utilization Management Authorization Grid for a quick reference of all services that need or do not need Prior Authorizations.